Healthcare Provider Details

I. General information

NPI: 1609814177
Provider Name (Legal Business Name): ELAINE ICBAN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 03/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4199 WASHINGTON ST SUITE 2
BOSTON MA
02131-1733
US

IV. Provider business mailing address

930 COMMONWEALTH AVE SUITE 2A
BOSTON MA
02215-1274
US

V. Phone/Fax

Practice location:
  • Phone: 617-587-5520
  • Fax: 617-587-5521
Mailing address:
  • Phone: 617-587-5511
  • Fax: 617-587-5514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4677
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: